Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced medical technique used in the diagnosis and treatment of diseases involving the pancreas and bile ducts. ERCP has become a vital tool for physicians, particularly in cases of acute pancreatitis. This technique has proven useful in identifying and treating causes such as microlithiasis, gallbladder disease, pancreas divisum, sphincter of Oddi dysfunction, tumors of the biliary tract or pancreas, pseudocysts, and pancreatic duct injuries.
Today, with the advent of less invasive techniques such as endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP), the role of ERCP has become primarily therapeutic, not just diagnostic.
What is acute pancreatitis?
Pancreatitis is an acute inflammatory condition affecting the pancreas and surrounding tissues. The 1992 Atlanta Symposium described it as a condition in which the pancreas becomes temporarily inflamed, and returns to normal after treatment.
In the United States, approximately 330,000 hospitalizations and over 900,000 doctor visits are due to pancreatitis alone each year. Gallstones and excessive alcohol consumption are the main causes. However, even if these factors are present, not everyone develops pancreatitis.
Origin and Complications of the Disease
Pancreatitis occurs when digestive enzymes such as trypsinogen become abnormally active and damage the pancreatic tissue itself. This results in acute inflammation, obstruction of blood flow, oxidative stress, and cellular damage. In severe cases, it can lead to respiratory failure, kidney failure, shock, and multi-organ failure. Approximately 20% of patients develop severe pancreatitis, and mortality rates range from 10% to 30%.
Diagnostic Use of ERCP
ERCP is used when a patient has clear signs of biliary tract obstruction—such as high bile salt levels, jaundice, or ductal obstruction on imaging. This is an invasive procedure, so it’s important to consider its potential risks (such as bleeding, infection, or recurrence of pancreatitis).
ERCP can cause complications in approximately 5–7% of cases. Therefore, it is currently preferred only in situations where it is medically necessary.
Microlithiasis and ERCP
Microlithiasis, or biliary sludge, is an important but often overlooked cause of pancreatitis. It is a fine, sticky substance containing mucin, cholesterol, and calcium bilirubinate. It can block the bile duct.
ERCP allows a bile sample to be taken for microscopic examination, which can confirm the diagnosis. If microlithiasis is found, the patient is treated with cholecystectomy or sphincterotomy.
Pancreas Divisum
This is a congenital abnormality of the pancreas, found in approximately 7–10% of people. The two ducts of the pancreas do not connect properly, obstructing the flow of digestive juices and leading to recurrent pancreatitis.
Relief is achieved by performing a sphincterotomy or stent placement on the minor papillae through ERCP. This procedure reduces the risk of recurrent pancreatitis.
Sphincter of Oddi Dysfunction (SOD)
This is a condition in which the sphincter of Oddi muscle does not function properly, obstructing the flow of bile and pancreatic juice. This can lead to recurrent pancreatitis.
There are three recognized types of SOD—
- Type I: Pain, enzyme elevation, and duct dilatation.
- Type II: Pain and one or two other symptoms.
- Type III: Pain alone, in the absence of other signs.
During ERCP, pressure is measured using sphincter manometry, and if greater than 40 mm Hg, treatment is performed with sphincterotomy.
Gallstones and ERCP
About half of pancreatitis cases in Western countries are caused by gallstones. If a stone becomes lodged in the bile duct, it can obstruct the pancreatic duct.
If the patient has signs of jaundice, biliary obstruction, or infection, the stone is removed by ERCP using a sphincterotomy. Patients who have had stones removed are recommended to undergo gallbladder surgery to prevent future recurrences.
Pancreatic Pseudocysts
Pseudocysts form when fluid and enzymes accumulate in the pancreas after inflammation. These cysts pose a risk of infection or rupture.
They can be removed or drained through ERCP, but this treatment is usually performed 4–6 weeks after the illness.
Pancreatic Duct Injury
In some cases, the pancreatic duct may rupture or become damaged, causing leakage of digestive juices and spreading infection.are.
ERCP identifies this leak and closes it with stent placement. Numerous studies have proven that this method results in faster duct repair and fewer complications.
Other Rare Causes
Sometimes, pancreatitis is caused by rare conditions—such as choledochal cysts, annular pancreas, or parasitic infections. In such cases, ERCP is both amenable to diagnosis and treatment.
Conclusion
Endoscopic retrograde cholangiopancreatography (ERCP) is playing a revolutionary role in the diagnosis and treatment of acute pancreatitis today. It not only identifies the cause but also provides immediate relief to the patient by removing obstructions in the bile or pancreatic ducts.
Although a complex and sensitive procedure, this treatment is highly effective under the supervision of experienced physicians. With the advent of newer technologies such as EUS and MRCP, the role of ERCP has now become primarily limited to therapeutic intervention—and this is its most significant achievement in modern medicine.
Key words: endoscopic retrograde cholangiopancreatography, ERCP, acute pancreatitis, gallstones, pancreas divisum, sphincter of Oddi dysfunction, pancreatic cysts, bile duct treatment.
